The Challenges of Treating ADHD as a Prescriber

I receive around two or three calls weekly for evaluation of ADHD in children and adults. Generally people have done some sort of questionnaire online and self diagnosed after answering six general questions. Or they have been receiving stimulants from their pediatrician, PCP, or other psychiatrist or APRN who is now requesting they transition care to psychiatry for whatever reason. They could have been on stimulants for years, having only completed a basic questionnaire at the time of the first prescription.

Diagnosing ADHD is hard. There are a lot of false positives because our brains and bodies are not supposed to sit for eight hours a day listening to lectures or working on a computer. So kids in high school and college who find lectures challenging often come to me stating they can’t pay attention to a three hour lecture. I’m thinking yeah but who can?

Depression is pretty straightforward. For a true severe depressive episode there is weight loss/gain, poor ability to function in daily life (decrease in showering, poorly groomed, missing work etc.), sleep increase or decrease, irritability…the list goes on. I’ve sat with enough depressed people on the spectrum from mild to severe with psychotic features that it in general fits a picture and there is overt evidence of impairment in functioning of the individual.

ADHD, especially in adults, is more subjective. Sometimes it takes a few sessions for me to see the full disorganization of their thought process. These are people who could be getting a 3.5 GPA telling me they can’t focus and can’t organize themselves. It’s hard for me to believe that when they are doing well academically. There’s also a lot to rule out. Anxiety disorders often present with difficulty focusing as do depressive disorders. Bipolar disorder has a high co-morbidity with ADHD and many times when bipolar patients are treated with mood stabilizers their focus improves. Trauma/abuse in children presents often as behavioral difficulties and difficulty focusing. I can’t tell you the number of kids I’ve assessed who have been diagnosed with ADHD but no one asked them about being sexually assaulted and how that is on their mind all the time making it impossible to focus.

I have adults who come to see me who are working two or three jobs, raising kids, getting maybe four hours of sleep per night telling me they have trouble concentrating and completing tasks. Chronic sleep deprivation can cause cognitive impairments. In other words without enough sleep you can’t think straight. Taking a stimulant would enhance anyone who is chronically tired. Taking a stimulant honestly would enhance anyone in general too.

What I look for in an assessment is thorough testing of some sort. Neuropsychiatric evaluation, or at the most basic a Conners Behavioral Rating Scale. Anything beyond a Vanderbilt really. Then I need to figure out how functioning is impaired. It needs to be impaired for me to offer medication. In the midst of all of this I have to assess for those who are drug seeking: those who would potentially sell their medications to others, and any other co-morbid substance abuse issues.

Then if I get through all of that and decide this person could benefit from some sort of medication for ADHD I have to warn about all the adverse effects. Because they exist. For real. I’ve seen stimulants make kids psychotic (visual hallucinations), more angry, irritable, lose weight due to decrease in appetite, stunt growth (yes I measure height and weight at every visit and rarely kids have needed Growth Hormone injections), and yes I’ve seen people who are addicted to stimulants. It’s a real thing.

Then we have to pick the stimulant to trial. There’s a bunch. I point blank don’t prescribe Adderall- it has a high, then a crash, and a wicked withdrawal, it also had a major street value and is the “most addicting”. Yet Adderall is the cheapest and the one all insurance companies want me to prescribe first. So for every stimulant prescription I write that’s a new prescription, new medication, I have to do a prior authorization. It’s a pain in the ass.

This is a side note. Adderall is supposedly the “cheapest” available. But Ritalin has been out on the market since 1952. So I’m confused as to why it is still wicked expensive. It’s generic now, yet pharmaceutical companies keep the price of stimulants jacked up. Read ADHD Nation. It’s a good book.

So, I do a thorough assessment, I provide drug education for my patient and/or their parents, I potentially send a urine toxicology screen, I fight the insurance company to cover the stimulant I feel is safest to prescribe. I call the pharmacy and the patient to tell them they can now pick up the stimulant. They try it. We do a follow-up. They don’t like it. “I just don’t feel like me.” “It makes me too tired.” “I have no appetite.” “It makes me angry.” “It makes me cloudy.” “My friends notice something’s not right.” The list goes on.

Round 2. We try another one. I have to do another prior authorization. I have to do more education. If it’s a college kid I have to make sure they get the old stimulant out of their dorm room and off the college campus to a place that destroys old medication.

Potential success with second medication trial. Or we go onto the third.

In my experience it can take 1-3 tries to find the right ADHD medication. I do prescribe non-stimulants as well.

We find the right medication. Then we have to taper to the right dose. Then it’s only lasting 6 hours they want it to last 8 or 10 or 16.

Then we have to have the discussion- my goals are to medicate someone to last a school day. My goal is not to have a person’s brain on a stimulant for sixteen hours a day. That’s not healthy. Then we may have to have the discussion of why they are running out of their medication early- because they are doubling their dose, or taking an added afternoon or evening dose to get through work or night classes. Then we have to revisit goals of treatment, misuse of medication….it goes on.

I don’t want people to think I don’t love treating ADHD. Because I do. When a thirteen or fourteen year old comes to me and is suffering and being made fun of at school and says the one thing they want to fix with medication “is to give me friends” well that just about breaks me and when I see them respond to ADHD medication and therapy and a year or two down the line they are functioning beautiful teenagers with friends and a social life and good grades, well that’s just about the best feeling in the world.

I’ve been in outpatient practice now for three and a half years. Some of the patient’s have been with me since day one. I started treating them as gangly and awkward thirteen year olds and they are now applying for college and asking me advice about sex and if they can smoke pot with their medications. It’s frightening watching these babies turn into men and women but it’s also amazing forging relationships with them and being a safe space for them to ask any question about anything. It’s also heart-melting to see them now have friends when a few years ago they felt like the most lonely kid in the world.

Those are my success stories and those are the reasons I still treat clients with ADHD. But there have been a lot of problems along the way too. I’ve seen clients who became irate and verbally aggressive because I wouldn’t prescribe them stimulants, specifically their Adderall. I now screen clients over the phone for intakes and am clear that I don’t prescribe that particular medication to weed out those issues.

Prescribing psychiatric medication is hard. Diagnosing psychiatric illness is hard. I take that responsibility very seriously and I try and be exceptionally thorough. Because for those suffering with ADHD I do want to help. But it can be exhausting and it is one of the few fields where patients come often thinking they know more than their healthcare provider about their diagnosis and course of treatment because of the tests they’ve taken online and subsequent research (many pharmaceutical companies are tricky and link ADHD questionnaires with websites about stimulants- you have a problem? Here’s the answer!).

For those truly suffering from ADHD I’m not trying to invalidate your experience. Because like I said, there are clients I treat with true ADHD who improve with therapy and medication and allowing me to be part of their journey is an honor. But to everyone else, you may not have ADHD- don’t jump to conclusions and please ask for a thorough evaluation before agreeing to the diagnosis. Also note that behavioral and cognitive therapy does help ADHD in addition to medication. Naturopath doctors also are around who treat ADHD if you are looking for an alternative approach.

Read legitimate sources and articles. ADHD Nation is great, the American Journal of Psychiatry has excellent articles about ADHD. Don’t depend on WebMD and pharmaceutical company websites. Be truly informed and don’t get mad when your healthcare provider recommends a thorough evaluation before jumping to a stimulant. Instead be thankful.